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NPI Code Detail

MEDICARE: DR. SHANE L ELLSWORTH DMD

MEDICARE: DR. SHANE L ELLSWORTH DMD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice DentistryD9517OR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1639379522
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHANE L ELLSWORTH DMD
Provider Business Mailing Address
First Line : 704 NE EVANS ST
Second Line :
City : MCMINNVILLE
State : OR
Zip : 97128-3926
Country : US
Telephone Number : 503-472-1402
Fax Number :
Provider Business Practice Location Address
First Line : 704 NE EVANS ST
Second Line :
City : MCMINNVILLE
State : OR
Zip : 97128-3926
Country : US
Telephone Number : 503-472-1404
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2007
Last Update Date : 01/06/2011

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